A stroke happens when blood vessels in the brain get blocked or broken. The result of a stroke is damage to the brain. Childhood stroke has several known causes. However, many causes are not well understood. A careful clinical examination and brain imaging can help diagnose stroke. Early treatment for stroke focuses on two things. The first is protecting the brain. The second is keeping its blood vessels open.
Most children with stroke will experience long-term neurological problems. They will likely require years of treatment. These treatments can address physical, developmental, and psychosocial complications from stroke.
DESCRIPTION AND DEFINITIONS
Children can experience three types of stroke.
Arterial Ischemic Stroke (AIS)
Arterial ischemic stroke is the most common type of childhood stroke. AIS occurs when an artery is blocked by a blood clot.
Arteries are the blood vessels that carry blood to the brain. Two pairs of arteries carry blood in the neck. The first pair are located at the front of the neck. They are called the carotid arteries. The second pair are located at the back of the neck. They are called the vertebral arteries.
After reaching the brain, these arteries connect in a circle. This circle is called the Circle of Willis. From there, the arteries spread out like tree branches. The largest branch is the middle cerebral artery. A lack of blood flow in these branches can lead to brain damage within minutes. This lack of blood flow is known as ischemia. The damage that results is a stroke.
Cerebral Sinovenous Thrombosis (CSVT)
In cerebral sinovenous thrombosis, blood clots occur in veins in the brain. The largest veins are called sinuses. Like all veins, sinuses carry blood back to the heart. Sometimes a blood clot occurs in the veins or sinuses. A clot can block the drainage of blood from the brain. Clots related to CSVT may lead to brain damage when they prevent blood flow.
Hemorrhagic Stroke (HS)
When a blood vessel breaks, or “hemorrhages,” in the brain, it causes a hemorrhagic stroke. During a hemorrhagic stroke, blood spills directly into brain tissue or spaces beside the brain. This can cause damage to the brain.
SYMPTOMS AND PHYSICAL SIGNS
Most strokes in children present with the SUDDEN ONSET of symptoms. These symptoms are neurological in nature.
Common examples include:
- Weakness of one side of the body. Weakness on one side of the body is called hemiparesis. Hemiparesis usually occurs in the face, arm, or leg.
- Difficulty speaking. A child may have difficulty making or understanding speech.
- Vision abnormalities. Vision loss occurs in one part of the visual world (e.g. they cannot see one half of the world regardless of which eye they use) or double vision.
- Dizziness or imbalance. A child may experience poor walking or coordination.
- Numbness of one side of the body. A feeling of decreased sensation or tingling.
These signs and symptoms may occur only briefly. When these symptoms resolve quickly, it is called a transient ischemic attack (TIA). TIA symptoms may be a warning sign for stroke.
Other symptoms may happen.
However, these conditions are usually due to something other than stroke:
RISK FACTORS AND CAUSATION
The causes of stroke in children are not well understood. There is usually nothing a child, parent, or anyone else could have done to prevent a stroke. First strokes in children are nearly impossible to prevent.
Some children have multiple risk factors that combine to result in stroke. Others have no risk factors, but still experience stroke. Sometimes medical professionals can find no risk factors in spite of extensive investigation. In these cases, they use the term idiopathic stroke.
Possible Causes of Arterial Ischemic Stroke (AIS) in Children
Arteriopathy means “sick artery.” There are various arteriopathies that can lead to childhood AIS. Arteriopathy can be related to:
- Focal cerebral arteriopathy (FCA). FCA generally occurs in healthy children. It affects the arteries on one side of the brain. It progresses over days or weeks. The exact cause of FCA is unknown. However, it may relate to a recent infection.
- Vasculitis. An inflammation of the blood vessels is called vasculitis. Focal cerebral arteriopathy (FCA) may be a form of vasculitis.
- Infection. Certain infections can directly cause artery problems. Bacterial meningitis is an example.
- Dissection. A tear in the wall of an artery is called dissection. Some dissections are associated with physical trauma.
- Moyamoya. Moyamoya is a progressive narrowing of the carotid arteries on both sides of the brain. It can cause compromised blood flow, clot formation, or bleeding. Moyamoya is usually related to a genetic condition.
- Genetics. Several other rare genetic conditions may lead to arteriopathy.
Heart conditions are a major risk factor for childhood AIS. Complex congenital heart disease can include malformations in heart development. These can increase the risk of stroke. So can the surgical procedures used to treat them.
Other cardiac risks for AIS include:
- low heart function
- abnormal rhythm
- valve disease
- heart infection (endocarditis)
- treatments for severe heart failure
Blood conditions may contribute to AIS in children.
- Blood clotting disorders. These are also called thrombophilias or prothrombotic disorders.
- Sickle-cell disease. Sickle-cell is a genetic blood condition that carries a very high risk of stroke.
- Iron deficiency anemia. Anemia is a common condition in young children. In rare instances, it is associated with stroke.
Possible Causes of Cerebral Sinovenous Thrombosis (CSVT) in Children
- Infections. Bacterial meningitis and serious middle ear infections can cause CSVT.
- Dehydration. Increases the risk of abnormal blood clotting.
- Blood clotting disorders. These are also called thrombophilias or prothrombotic disorders.
- Systemic diseases. Some medical conditions can increase the risk of CSVT. Examples include inflammatory bowel disease, nephrotic syndrome, and many cancers. Their treatments can also increase the risk of CSVT.
- Trauma. Physical injury to the sinuses can lead to CSVT.
Possible Causes of Hemorrhagic Stroke (HS) in Children
Hemorrhagic stroke often involves the rupture of an abnormal blood vessel in the brain. Blood disorders or other conditions may also be responsible. Possible causes of HS include:
- Arteriovenous malformations. These are abnormal tangles of arteries and veins. They are the leading cause of hemorrhagic stroke in children.
- Cavernous malformations. These are another type of vascular malformation. They involve smaller blood vessels in the brain.
- Aneurysms. Aneurysms are outpouchings of cerebral arteries. They are uncommon in children. However, they may be involved in the genetic, infectious, and traumatic causes of HS.
- Arteriopathies. Some arteriopathies can also predispose a child to hemorrhagic stroke.
- Blood disorders. Some disorders impair the blood’s ability to clot. These can increase the risk of hemorrhagic stroke. Examples include:
- genetic conditions (such as hemophilia)
- disorders of the coagulation system (such as liver failure) low blood platelets
- the use of some medications
- Brain tumors and physical trauma. Both tumors and trauma can lead to hemorrhagic stroke.
A neurologist requires brain imaging to diagnose stroke in children. This brain imaging can be used to assess the brain and its blood vessels. There are two types of brain imaging techniques. The first is called a CT scan, and the second is called an MRI.
Computer Assisted Tomography (CT or CAT) Scan
Computer assisted tomography scans are quick and widely available. CT scans do not require sedation or anesthesia because they can be done in minutes. They are good at detecting strokes. CT scans can produce images of the brain’s arteries and veins. CT angiography (CTA) can produce images of arteries. Meanwhile, CT venography (CTV) can produce images of veins.
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging is the most sensitive test available for diagnosing a stroke in children. However, its longer scan times may require sedation for younger children. Like CT scans, MRIs can produce images of the brain’s arteries and veins. MR angiography (MRA) can produce images of arteries. MR venography (MRV) can produce images of veins.
Neuroimaging (CT scans and MRIs) can confirm a diagnosis of stroke in children. They can often identify a stroke’s primary cause. However, many children require further laboratory tests in order to uncover possible risk factors.
Doctors may order the following laboratory tests:
- Echocardiograms (ECHO). ECHOs create an ultrasound picture of the heart.
- Electrocardiograms (ECG). ECGs trace the heart’s rhythm.
- Electroencephalograms (EEG). EEGs test brain activity. They may be useful in evaluating seizure-related complications of stroke.
- Blood clotting tests. These tests can exclude bleeding or clotting disorders.
- Other blood tests. Other blood tests include cell counts, kidney and liver tests, and inflammation marker tests.
- Lumbar punctures. Lumbar punctures test for infection or inflammation. They are also called “spinal taps.”
The early treatment of childhood stroke focuses on protecting the freshly injured brain. Early treatments for stroke include:
Neuroprotection means using supportive measures to minimize brain injury. For instance:
- correcting dehydration
- maintaining normal blood sugars
- avoiding increased body temperatures
- treating infections
- recognizing and treating seizures
- maintaining good blood pressure (this optimizes blood flow to the brain)
Additional Early Management Methods
Other early management methods vary based on the type and cause of stroke.
- Antibiotics. Strokes related to infection usually require antibiotics.
- Corticosteroids. Strokes related to inflammation may be treated with steroids.
- Blood transfusions. Strokes related to sickle cell disease may require blood transfusions.
Opening Blocked Vessels
Opening blocked vessels is known as recanalization. Opening blocked vessels is sometimes used to treat childhood stroke. However, evidence of its safety and effectiveness in children is limited. Methods include:
- thrombolytic, or “clot busting,” drugs
- special procedures to manually remove blood clots
Blood–thinning medicines are safe for use in children with stroke.
Blood thinners help prevent the growth or development of new blood clots. The type and duration of a blood thinner can vary. The two primary blood thinner types prescribed after a childhood stroke are:
- those that affect the coagulation system (such as heparin)
- those that affect the platelets (such as aspirin)
Preventing Increased Intracranial Pressure
High pressure in the head is immediately life threatening. Increased pressure may occur immediately after a hemorrhagic stroke. It may also occur within days of any type of stroke. Some individuals may require neurosurgery to alleviate this pressure.
OUTCOMES AND CHRONIC MANAGEMENT
Outcomes from childhood stroke vary. Many factors determine the outcomes of childhood stroke. However, only some of these factors are understood. Therefore, it is difficult to predict an outcome soon after a stroke. Virtually all children will improve with time.
Childhood stroke may include long-term complications. However, there are established methods for managing these complications.
- Hemiparesis. Weakness on one side of the body is a common complication of childhood stroke. Pediatric occupational therapists and physical therapists can help treat hemiparesis in children.
- Epilepsy. Childhood stroke can lead to recurrent seizures. These seizures can often be managed with medication.
- Language disorders. Language disorders may include difficulty with speaking or with understanding language. Therapy from a speech-language pathologist can help.
- Movement disorders. Abnormal movements of an arm or leg may sometimes be treated with therapy and medication.
- Cognition and learning. Changes in cognition or learning ability may require examination by a neuropsychologist. Talking to teachers and education experts can also help.
- Family mental health. Struggles with mental health can be common in family members after a childhood stroke. Screenings for depression, anxiety, and other mental health conditions are sometimes required. Family-centered care models and peer-support groups can be beneficial.
Depending on its cause, a childhood stroke may carry a risk of recurrence. However, some established strategies can help prevent recurrence. These include:
- regular follow-ups and repeated imaging (for high-risk conditions)
- antithrombotic therapy, often with aspirin
- anticoagulation therapy, often with warfarin
- special surgeries (for conditions like moyamoya)
- special treatments, such as blood transfusions (for sickle cell disease)
- basic principles of good health, including an active lifestyle and balance diet
Little Stroke Warriors Australia (Facebook community group)
Little Stroke Warriors Australia is a group of families and survivors of paediatric stroke. It provides families and caregivers with a supportive community to help steer them through the journey of stroke recovery. Little Stroke Warriors also raises awareness of paediatric stroke throughout Australia, to make sure all paediatric stroke survivors get the treatment and care they need, and that their families are well supported.
Little Stroke Warriors also hosts a private Facebook group that anyone worldwide can join: Little Stroke Warriors Support Group.
Fight the Stroke Foundation (Based in Italy)
FightTheStroke exists to answer the need for knowledge and support for families impacted by the management of a young stroke survivor and with a disability of Cerebral Palsy; to educate to the awareness that children, even those not yet born, can be affected by stroke; to inspire the new generations and encourage research and adoption of innovative therapies. Although based in Italy, FightTheStroke actively collaborates internationally on scientific and social innovation.
International Alliance for Pediatric Stroke
The International Alliance for Pediatric Stroke (IAPS) is dedicated to building awareness, expanding education, providing support, and advancing research on behalf of children and their families, leading to a timely diagnosis, treatment, and prevention of pediatric stroke. The website contains vetted, useful information, the IAPS Support Network, resources, stories, and much more.
Pediatric Stroke Parent Support Group (Aurora, Colorado)
The Pediatric Stroke Parent Support Group is a monthly meeting for families of stroke survivors. This community provides support, education, and advocacy for families impacted by the range of outcomes of all types of pediatric strokes. Normally the group meets in person on the second Tuesday of the month. However, due to COVID-19, the group has been meeting online via Zoom. Anyone is welcome to join the online meetings. Please check the website for up-to-date meeting information. Connect via Facebook or email: firstname.lastname@example.org
International Pediatric Stroke Organization
The mission of the International Pediatric Stroke Organization (IPSO) is to improve the lives of children with cerebrovascular disease worldwide through research, education, clinical care and advocacy. IPSO’s vision is a world in which international, multidisciplinary collaborations advance the understanding, care, and outcomes of childhood cerebrovascular disease.
KISS Pediatric Stroke Support Group (Facebook private group)
KISS Pediatric Stroke Support Group is a safe space offering not just support to the parents and caregivers navigating the often overwhelming journey of life after pediatric stroke, but it’s also a place to ensure that all stroke families are up to date on the most cutting-edge information pertaining to pediatric stroke: research, educational tools, and advocacy campaigns to support and rally for our children both in our local communities and worldwide.
The Stroke Association (UK based)
The Stroke Association’s core purpose is to be the trusted voice of stroke survivors and their families, and to drive better outcomes in stroke prevention, treatment, and lifelong support for everyone affected by stroke. The Childhood Stroke section of the website https://www.stroke.org.uk/childhood-stroke includes information, publications and resources.
The Brain Recovery Project: Childhood Epilepsy Surgery Foundation
The Brain Recovery Project (BRP) provides research-based, reliable information to help parents and caregivers understand when a child’s seizures are drug-resistant. The BRP team explains the risks and dangers of seizures and helps families weigh the pros and cons of the various brain surgeries to stop them. Caring BRP team members also help parents understand the medical, cognitive, and behavioral challenges a child may have through life, as well as guide parents through financial and life care issues, and the IEP process. If desired, parents can connect with other families for support. The Brain Recovery Project also hosts a private Facebook group, Education After Pediatric Epilepsy Surgery with over 200 members.
In addition, BRP has resources for medical professionals to assist in helping clinicians help the parents of their patients find the resources they need after surgery. Educators and therapists will also find helpful resources and information including videos, guides, and relevant research. Patients who have undergone surgery are encouraged to register with the Global Pediatric Epilepsy Surgery Registry to help in setting future research priorities.
Pediatric Stroke Family Tool Kit
The International Alliance for Pediatric Stroke has published the Pediatric Stroke Family Tool Kit, a must-have guide for anyone who has a baby, child, or teen who has had a stroke. The Tool Kit is available online to download, flip through, and printed copies are also available at no cost.
Fact sheet created in partnership between International Alliance for Pediatric Stroke and the American Stroke Association. Appropriate for sharing in the community, on social media, schools, physicians’ offices. Printed copies are available through contacting IAPS at email@example.com.
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ClincalTrials.gov for Pediatric Stroke are clinical trials that are recruiting or will be recruiting. Updates are made daily, so you are encouraged to check back frequently.
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All four of these girls from Kansas City, MO suffered massive strokes during their high school careers. After long and hard recoveries, all four were able to graduate on time.
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Reviews and Guidelines:
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, et al. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation. 2013;128(24):2622–703. http://doi.org/10.1161/01.cir.0000436140.77832.7a
Ichord R. Cerebral Sinovenous Thrombosis. Frontiers in Pediatrics. 2017;5. http://doi.org/10.3389/fped.2017.00163
Kirton A, Deveber G. Paediatric stroke: pressing issues and promising directions. The Lancet Neurology. 2015;14(1):92–102. http://doi.org/10.1016/S1474-4422(14)70227-3
Lo WD. Childhood Hemorrhagic Stroke. Journal of Child Neurology. 2011;26(9):1174–85. http://doi.org/10.1177/0883073811408424
Medley TL, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, et al. Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke. International Journal of Stroke. 2018;14(1):94–106. http://doi.org/10.1177/1747493018799958
Monagle P, Chan AK, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, et al. Antithrombotic Therapy in Neonates and Children. Chest. 2012;141(2). http://doi.org/10.1378/chest.11-2308
Sinclair AJ, Fox CK, Ichord RN, Almond CS, Bernard TJ, Beslow LA, et al. Stroke in Children With Cardiac Disease: Report From the International Pediatric Stroke Study Group Symposium. Pediatric Neurology. 2015;52(1):5–15. http://doi.org/10.1016/j.pediatrneurol.2014.09.016